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Uriatry: A Concept
Ttt!G JOURNAL OF UROLOGY
Vol. 73, No. 5, ~fay 1955 Pn·ntcd in U.S.A.
URIATRY: A CONCEPT GEZA SCHINAGEL From. the Department of Urology, Patton State Hospital, California Department of Mental Hygiene
In a study of cases of urogenital lesions at Patton State Hospital (California Department of Mental Hygiene) it was found that some of these patients presented such a complex clinical picture that the lesions were not discovered by initial examination, misdiagnosed or given belated or inadequate therapy. This was true even when psychosomatic factors were considered in patients with complex clinical pictures. There were symptoms present at the time of examination which were due to disturbances of other organic systems and created an uneven, confused and apparently misleading clinical and psychosomatic picture. It became important, therefore, to attempt to classify these symptoms of divergent clinical and pathological manifestations into one syndrome in order to better identify and treat urogenital lesions. If we place in the center of these complexes, the common denominator, the initial urogenital component, we thereby stress a uniformity in correlating diversified symptoms even if the total clinical picture is far removed from the consequences of urogenital disturbances. This can be expressed by using the concept of uriatry, stressing thereby the physician's part of it. It is assumed that the primary factor of the disturbances in these observed cases is a urogenital one. This component of the clinical picture is so well camouflaged by the many symptoms derived from manifold causes that it must literally be dug out to arrive at the uriatric concept. It would be very simple to regard these symptom complexes as an end process of a urologically missed lesion, but this would not uncover the entire picture. V\T e must therefore 1Yiden our point of view. '\~Te should regard the whole patient as a clinical entity and avoid the pitfall of seeing only through the magnifying glass of the organ specialist. We must acknowledge, ,vhen reviewing such complex clinical pictures, that very often there can be an overlapping relationship between urology and other medical branches. Psychiatry, as such, is the "filler in." The expression, uriatry is an approach to this new concept. It is used solely as a methodological concept even if the term may be regarded by some as unnecessary. '\~That is the mechanism of uriatry? It must be assumed that the initial organic lesion of the urogenital system is a dynamic cause, a trigger mechanism. If this is not properly attended, it elicits a process of adaptation. In line with this adaptation a morphological, or organic, disturbance or adjustment follows. On the bases of the behavioral, or the psychological pattern of the individual, this elicits emotional tension, which, in turn, may influence any vegetative system. Accepted for publication October 8, 1954. 873
874
GEZA SCHINAGEL
The various vegetative responses appear in the different vegetative functions with multiple and manifold symptoms. And, if to these symptoms are added iatrogenic interferences (either with positive or negative results), the clinical picture may be a most confusing one. The urological aspect, until now, is divided according to the different medical branches. This division is convenient for study, but it appears to be insufficient and disturbing from the clinical point of view when we regard the whole aspect of the individual organism. As uriatry comprises this whole clinical complex we should, rather, speak about gynecologic, pediatric, psychiatric, ophthalmologic, geriatric, oncologic, etc. uriatry, and not speak of "urology," which strictly analyzed, pertains to the lesions of the genito-urinary organs only. With the conception of uriatry, we are able to cover not only the field of the psychic influences on micturition, but also the territory of psychic disturbances due to organic genito-urinary causes. CASE ABSTRACTS
To substantiate this concept, the following abbreviated case histories have been selected from the abundant clinical material at the hospital. In these cases the most conspicuous symptoms have been due to mental disturbances, although the initial lesions appear to have been genito-urinary. Case 1. M. M., a 35 year old white nurse, who was referred to urology because of "hematuria", was found to have ruptured villi of the internal vesical orifice. She was a habitual drug addict. The surgical scars on the abdominal wall, the result of 12 major operations (fig. I) aroused interest. After considerable investigation her history revealed that at 6 years of age she had scarlet fever with "kidney complications on the right side." At sixteen she had an appendectomy because of pains in the right side, followed by peritonitis. Because of "bowel obstructions" she had separation of adhesions at eighteen and again at twenty. After the latter operation, a diagnosis of tuberculous peritonitis was made. Her recovery was stormy, complicated with renal insufficiency, which necessitated a urological examination. It was found she had an anomalously inserted ureter into the right kidney pelvis. A renal pelvic plastic operation was performed (age 22) which was followed by pneumonia and a perinephric abscess, which was drained. The following year a right nephrectomy was performed because the plastic operation had not been successful. At the time it was found that she had a Bacillus abortus infection of the left kidney. After one of the many ureteral catheterizations, a paranephric abscess developed on the left side and was surgically drained. Because of an obstructive ileus, based on intra-abdominal adhesions, she underwent a resection of the bowel performed by absolutely reputable surgeons, at the ages of 29, 30 and 31. She tried to justify her drug addiction by saying that "before and after these
URIATRY
875
FIG. 1
many surgical procedures, I was in constant pain and I just wanted to be well." Comment: It appears that the congenitally anomalous right kidney elicited symptoms which led to an appendectomy with intra-abdominal complications. The multiple surgical interferences brought personality changes, one phase being her drug addiction. The symptoms of this uriatric patient could be classified, if each were taken independently at a specific time, as surgical, internal medical, tuberculotic, psychiatric or urologic. From the uriatric point of view, they are only a part of this broader concept. Case 2. R. F., a 74 year old white man, ·who several times attempted suicide, was melancholic and depressed. He complained that there was no medication for "that old cancer in my breast" pointing to his enlarged breasts, which started ·with treatment of his prostatic troubles. Nine years ago he underwent transurethral prostatic resection; the following year, bilateral orchiectomy. Since that time he had been intermittently on stilbestrol medication. Examination shmved (fig. 2) a feminine fat distribution (enlarged breasts, etc.) soft skin, pubic hair change, and a scarce beard growth ("I stopped shaving"). The circumference of the right leg was enlarged. The prostate was stone-hard and indurated. Ostcoblastic changes were found in the lumbar and thoracic spine. The serum acid and alkaline phosphatases were increased. Comment: The castration and intensive estrogenic medication influenced both his metastatic prostatic cancer and his body constitution by feminizing this 74 year old man. This appears to have been elicited by a psychotic disturbance, a
876
GEZA SCHINAGEL
reactive depression, with melancholia, which clinical picture was in the foreground. In this uriatric patient symptoms of psychiatric, oncologic, endocrine and urological disturbances have been present. Case 3. D. B., a 20 year old white man, was referred because of urinary retention. He was mentally disturbed, sullen, morose, and told rather fantastic stories about urological treatment, especially following his recent urological operation. His kidney function was impaired (phenolsulfonphthalein output in 2 hours only 12 per cent); the nonprotein nitrogen was 125 mg. per cent. The blood pressure was 210/115. Eye fundus examination showed extensive areas of "cotton wool" exudates throughout the retina, with suggestive papilledema with optic atrophy.
FIG. 2
Because of "renal disease" he was urologically examined at the age of 3 months and again at 10 years. (The diagnosis was bilateral hydronephroses and hydroureters, but no treatments were instituted at that time.) Because his urinary stream was diminishing, he had a complete urological examination. This revealed that the anterior lobe of the prostate was enlarged, the bladder atonic and trabeculated, with a deep bas fond and 180 cc residual urine. The pyelograms revealed bilaterally bifurcated kidney pelves, with a lateral take off of the ureters, but no polycystic kidneys. The ureters were dilated. After removal of 10 gm. of the anterior prostate lobe transurethrally, visual difficulties developed and the patient became mentally more disturbed. Comment: Failure to correct these congenital urogenital malformations at an early age produced an advancing kidney insufficiency. This preuremic state was influenced by the stress of operative interference, at this late stage, manifesting itself in a psychosis and visual disturbances. Although these symptoms have been
URIATRY
877
in the foreground in his clinical picture, the fundamental disturbance was a urological one. The syn1ptoms of this uriatric patient have been psychiatric, medical, ophthalmologic and urologic. Case 4- A. S., a 22 year old white woman, attempted suicide twice, once after a cystocele operation. She complained of pain on urination, and urgency and frequency. She was raped at the age of 13 with consequent cystopyelitis. She ,vas married at 15. Her husband abandoned her during her pregnancy at the age of 17. At 19 she married a 34 year old nian. Since that time her urinary syrnptoms were aggravated considerably, especially after coitus. On cystoscopic examination, a stricture of the right ureter was found. Previous to this diagnosis (because of pain on the right side), she had undergone appendectomy, uterine suspension and right salpingectomy. It was found that she had a number of psychoneurotic components, too, such as hysteria, hypochondria and reactive depression, which led to her suicidal attempts. Comment: The initial urogenital lesion was defloration cystopyelitis, followed probably by the ureteral stricture. The symptoms of this lesion led to surgical polypragmasia, which aggravated the latent psychoneurotic mental factor and led to her disturbed personality. This uriatric patient had gynecological, sexological, psychiatric and nrologic symptoms. Case 5. V. K., a 32 year old white male drug addict, was a bed wetter until the age of 8. At 17 (in 1939) he suffered a bomb blast in England -with a consequent pain on the right side, which necessitated an exploratory laparotomy, but no explanation was found for the pain. As it continued, in 1941 (age 19), a right nephropexy was performed with subsequent postoperative infection and drainage. From then on he had frequent attacks of ureteral colic on the right side. Finally, in 1946, the ureteral calculi were removed cystoscopically. It was during this time that the narcotic habit developed. In 1946 he was in a train wreck and his right kidney tore loose again. It was resuspended. Postoperative infection developed and a perirenal abscess was drained 5 months afterward. Since that time he has had a mixed colon type pyelonephritis on the right side, with frequent ureteral spasms. Finally, in 1950 he underwent a right nephrectomy. (He also had a resection of the bladder neck during one of his 27 cystoscopies.) At present examination he suffered from a strictured prostatic urethra, a definite median bar of the bladder neck with a nonspecific infection of the lower tract, extending into the right ureteral stump and painful peri-ureteritis. Comment: The bomb blast started the process. Due to ptosis of the right kidney, with stasis and stone formation, the patient had been subjected to frequent surgical interference. The sufferings because of the ptosis led the already labile psychotic personality (his bedwetting) to deeper disturbances, with consequent addiction.
878
GEZA SCHINAGEL
This uriatric patient had symptoms which can be classified as general surgery, psychiatry and urology. Case 6. B. S., a 59 year old white man, was classified as a sexual psychopath. He had continuous urinary urgency, with dysuria, which made him irritable and uncooperative. Two years ago he had a right nephrectomy because of a tuberculous kidney. Previously he had an appendectomy. Examination showed a contracted bladder of 100 cc capacity, and some ulcerations on its wall. The prostatic urethra was rigidly strictured and tilted anteriorly. The left epididymis was tender; the left seminal vesicle was hard. The left kidney function was decreased (phenolsulfonphthalein only 38 per cent in 2 hours), and its infundibula were narrowed. Tubercle bacilli were found in the urine. In his childhood the patient was "sickly and high strung," rather intellectual, and "suffered always from frequent urination." His urinary disturbances led him to early masturbation. At the age of 9 he started to rubbing his penis against young girls' genitalia. He had his first heterosexual experience at 17. He was married at 24, but divorced as his wife was "not interested and sickly." He fondled little girls (in his estimation at least 150) but denied any penetration whatsoever. Comment: His inflammatory (probably tuberculous) urinary disturbances predisposed him to early sexuality. As his physical constitution (because of early tuberculosis?) was under par, the stress of livelihood, and marital disturbances, led him into compensatory activities. First he became an excessive alcoholic. Later, diverting from this for his satisfaction, he transferred to the sexual sphere, seeking to relive the pattern of his early experiences. As his genito-urinary tuberculosis was apparent, surgical polypragmasia was not successful. SUMMARY
For evaluating pathological manifestations of different organ systems, where the initial lesion is urogenital, the concept of uriatry is introduced. Uriatry is a reorientation, designed to express a uniform clinical point of view. The author wishes to express his appreciation of the assistance of Otto L. Gericke, M.D., Superintendent and Medical Director of the Hospital, in carrying out this work.
Vol. 73, No. 5, ~fay 1955 Pn·ntcd in U.S.A.
URIATRY: A CONCEPT GEZA SCHINAGEL From. the Department of Urology, Patton State Hospital, California Department of Mental Hygiene
In a study of cases of urogenital lesions at Patton State Hospital (California Department of Mental Hygiene) it was found that some of these patients presented such a complex clinical picture that the lesions were not discovered by initial examination, misdiagnosed or given belated or inadequate therapy. This was true even when psychosomatic factors were considered in patients with complex clinical pictures. There were symptoms present at the time of examination which were due to disturbances of other organic systems and created an uneven, confused and apparently misleading clinical and psychosomatic picture. It became important, therefore, to attempt to classify these symptoms of divergent clinical and pathological manifestations into one syndrome in order to better identify and treat urogenital lesions. If we place in the center of these complexes, the common denominator, the initial urogenital component, we thereby stress a uniformity in correlating diversified symptoms even if the total clinical picture is far removed from the consequences of urogenital disturbances. This can be expressed by using the concept of uriatry, stressing thereby the physician's part of it. It is assumed that the primary factor of the disturbances in these observed cases is a urogenital one. This component of the clinical picture is so well camouflaged by the many symptoms derived from manifold causes that it must literally be dug out to arrive at the uriatric concept. It would be very simple to regard these symptom complexes as an end process of a urologically missed lesion, but this would not uncover the entire picture. V\T e must therefore 1Yiden our point of view. '\~Te should regard the whole patient as a clinical entity and avoid the pitfall of seeing only through the magnifying glass of the organ specialist. We must acknowledge, ,vhen reviewing such complex clinical pictures, that very often there can be an overlapping relationship between urology and other medical branches. Psychiatry, as such, is the "filler in." The expression, uriatry is an approach to this new concept. It is used solely as a methodological concept even if the term may be regarded by some as unnecessary. '\~That is the mechanism of uriatry? It must be assumed that the initial organic lesion of the urogenital system is a dynamic cause, a trigger mechanism. If this is not properly attended, it elicits a process of adaptation. In line with this adaptation a morphological, or organic, disturbance or adjustment follows. On the bases of the behavioral, or the psychological pattern of the individual, this elicits emotional tension, which, in turn, may influence any vegetative system. Accepted for publication October 8, 1954. 873
874
GEZA SCHINAGEL
The various vegetative responses appear in the different vegetative functions with multiple and manifold symptoms. And, if to these symptoms are added iatrogenic interferences (either with positive or negative results), the clinical picture may be a most confusing one. The urological aspect, until now, is divided according to the different medical branches. This division is convenient for study, but it appears to be insufficient and disturbing from the clinical point of view when we regard the whole aspect of the individual organism. As uriatry comprises this whole clinical complex we should, rather, speak about gynecologic, pediatric, psychiatric, ophthalmologic, geriatric, oncologic, etc. uriatry, and not speak of "urology," which strictly analyzed, pertains to the lesions of the genito-urinary organs only. With the conception of uriatry, we are able to cover not only the field of the psychic influences on micturition, but also the territory of psychic disturbances due to organic genito-urinary causes. CASE ABSTRACTS
To substantiate this concept, the following abbreviated case histories have been selected from the abundant clinical material at the hospital. In these cases the most conspicuous symptoms have been due to mental disturbances, although the initial lesions appear to have been genito-urinary. Case 1. M. M., a 35 year old white nurse, who was referred to urology because of "hematuria", was found to have ruptured villi of the internal vesical orifice. She was a habitual drug addict. The surgical scars on the abdominal wall, the result of 12 major operations (fig. I) aroused interest. After considerable investigation her history revealed that at 6 years of age she had scarlet fever with "kidney complications on the right side." At sixteen she had an appendectomy because of pains in the right side, followed by peritonitis. Because of "bowel obstructions" she had separation of adhesions at eighteen and again at twenty. After the latter operation, a diagnosis of tuberculous peritonitis was made. Her recovery was stormy, complicated with renal insufficiency, which necessitated a urological examination. It was found she had an anomalously inserted ureter into the right kidney pelvis. A renal pelvic plastic operation was performed (age 22) which was followed by pneumonia and a perinephric abscess, which was drained. The following year a right nephrectomy was performed because the plastic operation had not been successful. At the time it was found that she had a Bacillus abortus infection of the left kidney. After one of the many ureteral catheterizations, a paranephric abscess developed on the left side and was surgically drained. Because of an obstructive ileus, based on intra-abdominal adhesions, she underwent a resection of the bowel performed by absolutely reputable surgeons, at the ages of 29, 30 and 31. She tried to justify her drug addiction by saying that "before and after these
URIATRY
875
FIG. 1
many surgical procedures, I was in constant pain and I just wanted to be well." Comment: It appears that the congenitally anomalous right kidney elicited symptoms which led to an appendectomy with intra-abdominal complications. The multiple surgical interferences brought personality changes, one phase being her drug addiction. The symptoms of this uriatric patient could be classified, if each were taken independently at a specific time, as surgical, internal medical, tuberculotic, psychiatric or urologic. From the uriatric point of view, they are only a part of this broader concept. Case 2. R. F., a 74 year old white man, ·who several times attempted suicide, was melancholic and depressed. He complained that there was no medication for "that old cancer in my breast" pointing to his enlarged breasts, which started ·with treatment of his prostatic troubles. Nine years ago he underwent transurethral prostatic resection; the following year, bilateral orchiectomy. Since that time he had been intermittently on stilbestrol medication. Examination shmved (fig. 2) a feminine fat distribution (enlarged breasts, etc.) soft skin, pubic hair change, and a scarce beard growth ("I stopped shaving"). The circumference of the right leg was enlarged. The prostate was stone-hard and indurated. Ostcoblastic changes were found in the lumbar and thoracic spine. The serum acid and alkaline phosphatases were increased. Comment: The castration and intensive estrogenic medication influenced both his metastatic prostatic cancer and his body constitution by feminizing this 74 year old man. This appears to have been elicited by a psychotic disturbance, a
876
GEZA SCHINAGEL
reactive depression, with melancholia, which clinical picture was in the foreground. In this uriatric patient symptoms of psychiatric, oncologic, endocrine and urological disturbances have been present. Case 3. D. B., a 20 year old white man, was referred because of urinary retention. He was mentally disturbed, sullen, morose, and told rather fantastic stories about urological treatment, especially following his recent urological operation. His kidney function was impaired (phenolsulfonphthalein output in 2 hours only 12 per cent); the nonprotein nitrogen was 125 mg. per cent. The blood pressure was 210/115. Eye fundus examination showed extensive areas of "cotton wool" exudates throughout the retina, with suggestive papilledema with optic atrophy.
FIG. 2
Because of "renal disease" he was urologically examined at the age of 3 months and again at 10 years. (The diagnosis was bilateral hydronephroses and hydroureters, but no treatments were instituted at that time.) Because his urinary stream was diminishing, he had a complete urological examination. This revealed that the anterior lobe of the prostate was enlarged, the bladder atonic and trabeculated, with a deep bas fond and 180 cc residual urine. The pyelograms revealed bilaterally bifurcated kidney pelves, with a lateral take off of the ureters, but no polycystic kidneys. The ureters were dilated. After removal of 10 gm. of the anterior prostate lobe transurethrally, visual difficulties developed and the patient became mentally more disturbed. Comment: Failure to correct these congenital urogenital malformations at an early age produced an advancing kidney insufficiency. This preuremic state was influenced by the stress of operative interference, at this late stage, manifesting itself in a psychosis and visual disturbances. Although these symptoms have been
URIATRY
877
in the foreground in his clinical picture, the fundamental disturbance was a urological one. The syn1ptoms of this uriatric patient have been psychiatric, medical, ophthalmologic and urologic. Case 4- A. S., a 22 year old white woman, attempted suicide twice, once after a cystocele operation. She complained of pain on urination, and urgency and frequency. She was raped at the age of 13 with consequent cystopyelitis. She ,vas married at 15. Her husband abandoned her during her pregnancy at the age of 17. At 19 she married a 34 year old nian. Since that time her urinary syrnptoms were aggravated considerably, especially after coitus. On cystoscopic examination, a stricture of the right ureter was found. Previous to this diagnosis (because of pain on the right side), she had undergone appendectomy, uterine suspension and right salpingectomy. It was found that she had a number of psychoneurotic components, too, such as hysteria, hypochondria and reactive depression, which led to her suicidal attempts. Comment: The initial urogenital lesion was defloration cystopyelitis, followed probably by the ureteral stricture. The symptoms of this lesion led to surgical polypragmasia, which aggravated the latent psychoneurotic mental factor and led to her disturbed personality. This uriatric patient had gynecological, sexological, psychiatric and nrologic symptoms. Case 5. V. K., a 32 year old white male drug addict, was a bed wetter until the age of 8. At 17 (in 1939) he suffered a bomb blast in England -with a consequent pain on the right side, which necessitated an exploratory laparotomy, but no explanation was found for the pain. As it continued, in 1941 (age 19), a right nephropexy was performed with subsequent postoperative infection and drainage. From then on he had frequent attacks of ureteral colic on the right side. Finally, in 1946, the ureteral calculi were removed cystoscopically. It was during this time that the narcotic habit developed. In 1946 he was in a train wreck and his right kidney tore loose again. It was resuspended. Postoperative infection developed and a perirenal abscess was drained 5 months afterward. Since that time he has had a mixed colon type pyelonephritis on the right side, with frequent ureteral spasms. Finally, in 1950 he underwent a right nephrectomy. (He also had a resection of the bladder neck during one of his 27 cystoscopies.) At present examination he suffered from a strictured prostatic urethra, a definite median bar of the bladder neck with a nonspecific infection of the lower tract, extending into the right ureteral stump and painful peri-ureteritis. Comment: The bomb blast started the process. Due to ptosis of the right kidney, with stasis and stone formation, the patient had been subjected to frequent surgical interference. The sufferings because of the ptosis led the already labile psychotic personality (his bedwetting) to deeper disturbances, with consequent addiction.
878
GEZA SCHINAGEL
This uriatric patient had symptoms which can be classified as general surgery, psychiatry and urology. Case 6. B. S., a 59 year old white man, was classified as a sexual psychopath. He had continuous urinary urgency, with dysuria, which made him irritable and uncooperative. Two years ago he had a right nephrectomy because of a tuberculous kidney. Previously he had an appendectomy. Examination showed a contracted bladder of 100 cc capacity, and some ulcerations on its wall. The prostatic urethra was rigidly strictured and tilted anteriorly. The left epididymis was tender; the left seminal vesicle was hard. The left kidney function was decreased (phenolsulfonphthalein only 38 per cent in 2 hours), and its infundibula were narrowed. Tubercle bacilli were found in the urine. In his childhood the patient was "sickly and high strung," rather intellectual, and "suffered always from frequent urination." His urinary disturbances led him to early masturbation. At the age of 9 he started to rubbing his penis against young girls' genitalia. He had his first heterosexual experience at 17. He was married at 24, but divorced as his wife was "not interested and sickly." He fondled little girls (in his estimation at least 150) but denied any penetration whatsoever. Comment: His inflammatory (probably tuberculous) urinary disturbances predisposed him to early sexuality. As his physical constitution (because of early tuberculosis?) was under par, the stress of livelihood, and marital disturbances, led him into compensatory activities. First he became an excessive alcoholic. Later, diverting from this for his satisfaction, he transferred to the sexual sphere, seeking to relive the pattern of his early experiences. As his genito-urinary tuberculosis was apparent, surgical polypragmasia was not successful. SUMMARY
For evaluating pathological manifestations of different organ systems, where the initial lesion is urogenital, the concept of uriatry is introduced. Uriatry is a reorientation, designed to express a uniform clinical point of view. The author wishes to express his appreciation of the assistance of Otto L. Gericke, M.D., Superintendent and Medical Director of the Hospital, in carrying out this work.